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SAN JOAOUIN C*UGT <br /> ELIC HEALTH SERVICES/ENVIRONMENTAL HEALT ISION <br /> Nin 0 <br /> 1, RKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> aME OF FACILITY SWEEPS CODE <br /> DORESS C;��` TANK 10 IY - <br /> LANK SIZE UEL TYPE <br /> it. GENERAL SITE HISTORY <br /> Is permit current? esermit 0 o acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teel I Fbrgt nit Dual Ij <br /> Ili. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired7 <br /> as repair done under inspection7 es qo ere soil samptes analyzed? es o TXE I PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfitt nknown cher: <br /> ;tV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es ilol epth to Ground Water of/Year ; verage Annual Precipitation k= 4 0-25 <br /> -Site Wells) es o umber & Type Irr em ub <br /> S core S cora S core <br /> istance to Welt(s) from Tank ft; ft; r ft C 10 pts C 7 pts C pts <br /> O if 0 if 0 f <br /> R ondition R condition R ondition <br /> i. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sanple {feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ample;Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T X E B JT X E <br /> MAXIMLM ALLOWABLE B-T-X-E LEVELS (PPH) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> `ample=Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evacuation <br /> "11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE (ESO <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED ¢ j <br /> L:VA <br /> E OF <br /> LUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />